Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) Facility fee (e.g., $200 copay per day up to If you have a hospital hospital room) $600 per individual per 50% coinsurance Provider must notify plan on admission. stay calendar year Physician/surgeon fees 15% coinsurance 50% coinsurance Preauthorization may be required. *See section Surgery. Outpatient services 15% coinsurance 50% coinsurance Preauthorization may be required. *See section Behavioral health. If you need mental $200 copay per day up to health, behavioral $600 per individual per Preauthorization required for inpatient admissions. health, or substance Inpatient services calendar year 50% coinsurance Provider must notify the plan for detoxification, abuse services intensive outpatient program, and partial Professional services: hospitalization. *See section Behavioral health. No charge Office visits 15% coinsurance 50% coinsurance Cost sharing does not apply for preventive services. Childbirth/delivery 15% coinsurance 50% coinsurance Depending on the type of services, a copayment, If you are pregnant professional services coinsurance or deductible may apply. Maternity care Childbirth/delivery $200 copay per day up to may include tests and services described elsewhere in facility services $600 per individual per 50% coinsurance the SBC (i.e. ultrasound). calendar year * For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc. Page 4 of 8